Family Name *

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Home Phone

(###)

###

####

Baby's Father's Cell Phone *

(###)

###

####

Baby's Mother's Cell Phone *

(###)

###

####

Date of Birth (English) *

MM

DD

YYYY

Time of Birth *

Hour

Minute

Second

AM PM

Date of Bris (English) *

MM

DD

YYYY

Davening Time

Hour

Minute

Second

AM PM

Bris Time

Hour

Minute

Second

AM PM

Baby's Mother's English & Maiden Name *

First Name

Last Name

Baby's Father's English Name *

First Name

Last Name

Baby's Father's Tribe *

Kohain

Laivi

Yisrael

Unknown/Other

Is your baby eating well and gaining weight? *

Yes

No

Not Sure

If you answered no/not sure, would you like more information about treating a tongue-tie and/or lip-tie?

Children may be born with a combination of conditions called a tongue-tie and/or lip-tie. These attachments can cause restrictions in movement, resulting in difficulty with breastfeeding. These concerns can generally be improved by a simple release done with a soft tissue laser. If the need should arise before the bris or our post-bris visits, as an Oral Surgeon, I can assist with laser frenectomies (also known as laser frenulectomy, laser frenotomy, or laser lip-tie or tongue-tie release) and would be happy to speak to your physician, midwife, and/or lactation consultant and provide guidance on treating a tongue or lip tie in your baby.

Yes, I'd like to learn more

No, thank you